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The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding?
- A. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes
- B. Inform the physician promptly that there is in imminent leak in the drainage system
- C. Encourage the patient to do deep breathing and coughing exercises
- D. Document that the chest drainage system is operating as it is intended
Correct Answer: D
Rationale: Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.
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A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
- A. To remove air from the pleural space
- B. To drain copious sputum secretions
- C. To monitor bleeding around the lungs
- D. To assist with mechanical ventilation
Correct Answer: A
Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?
- A. Fluid intake for the last 24 hours
- B. Baseline arterial blood gas (ABG) levels
- C. Prior outcomes of weaning
- D. Electrocardiogram (ECG) results
Correct Answer: B
Rationale: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patients record, and the nurse can refer to them before the weaning process begins.
The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?
- A. Safe technique for self-suctioning of secretions
- B. Technique for performing postural drainage
- C. Correct and safe use of oxygen therapy equipment
- D. How to provide safe and effective tracheostomy care
Correct Answer: C
Rationale: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use. The scenario does not indicate the patient needs help with suctioning, postural drainage, or tracheostomy care.
The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patients airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed?
- A. Continue suctioning the patient until no more secretions are obtained
- B. Perform chest physiotherapy rather than nasotracheal suctioning
- C. Wait several minutes and then repeat suctioning
- D. Perform postural drainage and then repeat suctioning
Correct Answer: C
Rationale: If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?
- A. Deflate the cuff overnight to prevent tracheal tissue trauma
- B. Inflate the cuff to the highest possible pressure in order to prevent aspiration
- C. Monitor the pressure in the cuff at least every 8 hours
- D. Keep the tracheostomy tube plugged at all times
Correct Answer: C
Rationale: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.